Personalised Menopause Symptom Tool
by Pause Project
Helping you to understand your symptoms better...
This tool is designed to help you reflect on your current menopausal symptoms. At the end of the questionnaire, you'll receive a personalised summary of your responses. *IF YOU ARE USING A MOBILE DEVICE, PLEASE TURN YOUR PHONE ON ITS SIDE SO THE SURVEY IS IN LANDSCAPE*
Name
*
First Name
Last Name
Email
*
(So you receive a copy of your results - It's Free!)
How much are you affected by the following symptoms?
Vasomotor Symptoms
None
Mild
Moderate
Severe
Very Severe
Hot Flushes
Night Sweats
Facial flushing or redness
Sensitivity to temperature changes (always hot or cold)
Heart palpitations or racing heartbeat
I would like help managing these symptoms
Yes
No
Maybe / Unsure
Vasomotor Symptom Score
Metabolic Symptoms
None
Mild
Moderate
Severe
Very Severe
Weight Gain
Difficulty loosing weight despite attempts to
Fatigue or tiredness
Fluid retention or puffiness
Getting sick more often or slower recovery from illness
I would like help managing these symptoms
Yes
No
Maybe / Unsure
Metabolic Symptom Score
Gut Symptoms
None
Mild
Moderate
Severe
Very Severe
Bloating or digestive discomfort
Change in bowel habits
Reflux or Heartburn
Food sensitivities
Sensitivity to alcohol or caffeine
I would like help managing these symptoms
Yes
No
Maybe / Unsure
Gut Symptom Score
Bones, Joints, Skin, Hair, Eye Symptoms
None
Mild
Moderate
Severe
Very Severe
Joint pain or stiffness
Muscle aches or cramps
Dry or itchy skin
Unwanted Hair growth or Hair loss
Dry Eyes
I would like help managing these symptoms
Yes
No
Maybe / Unsure
Bones, Joints, Skin, Hair, Eye Symptom Score
Neurological Symptoms
None
Mild
Moderate
Severe
Very Severe
Headaches or Migraines
Dizziness or feeling faint or lightheaded
Tingling, Numbness or Pins & Needles
Ringing in the Ears (Tinnitus)
Heightened skin sensitivity or unusual skin sensation
I would like help managing these symptoms
Yes
No
Maybe / Unsure
Neurological Symptom Score
Mental Health & Wellbeing Symptoms
None
Mild
Moderate
Severe
Very Severe
Feeling anxious or irritable
Low mood or sadness
Difficulty falling or staying asleep
Feeling flat, unmotivated or disengaged
Low self-worth or reduced confidence
I would like help managing these symptoms
Yes
No
Maybe / Unsure
Mental Health & Wellbeing Symptom Score
Brain-Fog & Cognitive Symptoms
None
Mild
Moderate
Severe
Very Severe
Difficulty concentrating
Poor Memory or forgetfulness
Slower mental processing or problem-solving
Difficulty focusing for long periods
Feeling mentally foggy or spaced out
I would like help managing these symptoms
Yes
No
Maybe / Unsure
Brain-Fog & Cognitive Symptom Score
Sexual Health & Genitourinary Symptoms
None
Mild
Moderate
Severe
Very Severe
Vaginal dryness or discomfort
Reduced libido or interest in sex
Frequent or urgent need to urinate
Incontinence or bladder leakage
Recurring urinary tract infections
I would like help managing these symptoms
Yes
No
Maybe / Unsure
I still need Contraception
Yes
No
Maybe / Unsure
Sexual Health & Genitourinary Symptom Score
Change in Menstrual Periods
None
Mild
Moderate
Severe
Very Severe
Unpredictable periods
Heavy periods
Painful periods
Long lengthy periods
Pre-menstrual mood changes
I would like help to manage my periods
Yes
No
Maybe / Unsure
Menstrual Period Symptom Score
How much are your symptoms impacting on your life?
None
Mild
Moderate
Severe
Very Severe
Impact on work or daily activities
Impact on home life
Impact on your close relationships
Impact on social life
Impact on overall quality of your life & overall happiness
Life Impact Symptom Score
Overall Menopause Score
The overall score is out of 200 points. The higher the score, the greater the potential impact of these symptoms on your life.
TOTAL SCORE
My Menopause Values
Fill in this section if you want to share your values & goals (and survey results) with your menopause health care provider.
What is important to you in your menopause care? What do you value most?
What would you like to achieve by speaking with your health care provider?
Select any key areas you specifically wish to address with your health care provider.
Confirmation of Peri/Menopause diagnosis
Education to improve my understanding on Peri/Menopause
Body-Identical Menopause Hormone Therapy (MHT) / Hormone Replacement Therapy (HRT)
Non-hormonal treatments
Complementary or Integrative therapies
Lifestyle & holistic approaches
Nutrition
Weight management advice
Physical activity and fitness
Mental health & wellbeing
Quality Sleep, Reduced fatigue
Brain-fog advice
Libido & sexual wellbeing
Contraception
Continence / Pelvic Floor
Help with my periods
Long-term chronic disease prevention (bone health, cardiovascular health, diabetes prevention etc)
Other health issues that I'm also experiencing
FREE PDF Results Summary
SUBMIT to receive your FREE PDF Summary! In submitting my responses, I acknowledge that this self-assessment tool is a guide only & for personal use only. Use is voluntary and at your own risk. No medical advice is provided and no liability is accepted for information provided. Feel free to download, save and print your submitted responses for personal use, including if you wish to take it to your menopause health professional.
I accept these terms.
Submit
Privacy and Consent Statement
By completing this survey, you agree to the collection of your information to produce you with a summary of your results. Details may be used to share survey updates, relevant resources, or other information we believe may be of interest to you. Survey responses are collected and stored via Jotform. You can read Jotform’s Privacy Policy here: https://www.jotform.com/privacy/. Your participation is voluntary. By proceeding, you confirm that you have read and understood this statement and consent to the use of your information as described.
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